Small-Cell Lung Cancer: Importance of Fiberoptic Bronchoscopy in the Evaluation of Complete Remission

The authors report their eight-year experience on the methodical of fiberbronchoscopy in the evaluation of complete remission in 140 patients affected by small-cell lung cancer. The higher reliability of fiberbronchoscopy than of standard chest X-ray is emphasized.

Subacute and chronic bird breeder hypersensitivity pneumonitis: sequential evaluation with CT and correlation with lung function tests and bronchoalveolar lavage

PURPOSE

To evaluate lung involvement in the subacute (group 1) and chronic (group 2) stages of bird breeder hypersensitivity pneumonitis.

MATERIALS AND METHODS

Computed tomographic (CT) findings in 45 patients were correlated with pulmonary function testing and bronchoalveolar lavage. Twenty-seven patients underwent sequential CT examination 0.3-4 years apart, with functional evaluation in 20 of them.

RESULTS

In group 1, CT showed diffuse micronodules, ground-glass attenuation, focal air trapping or emphysema, and mild fibrotic changes, with normal lung volumes but impaired diffusing capacity and a predominant lymphocyte alveolitis. In group 2, two categories of chronic forms were identified at CT on the basis of presence or absence of honeycombing. After cessation of exposure, CT showed a return to normal or dramatic improvement in group 1 and considerable reduction in ground-glass attenuation and micronodules in group 2. CT depicted no fibrotic or emphysematous changes during follow-up.

CONCLUSION

Subacute bird breeder hypersensitivity pneumonitis may share CT features with other types of hypersensitivity pneumonitis. CT may help in identification of emphysematous and fibrotic forms of chronic disease.

Depletion of OX-8 lymphocytes from the blood and airways using monoclonal antibodies enhances the late airway response in rats

Recent evidence supports a role for T lymphocytes in allergic airway responses. We hypothesized that reducing blood T suppressor cells (Ts) might increase the late airway response (LR). Sprague-Dawley (SD) rats were sensitized with ovalbumin (OA). On days 8, 10, and 12, post-sensitization test SD (n = 14) received monoclonal antibody intravenously (OX-8; 1 mg) specific to rat Ts. Controls received saline (n = 7) or mouse ascites IgG (n = 7). On day 14, animals were challenged with OA aerosol (5% wt/vol) for 5 min, lung resistance was recorded for 8 h (n = 18) and bronchoalveolar lavage was performed. The LR was determined from the area under the lung resistance vs time curve from 75 to 480 min after challenge. In the remaining 10 rats, airway lymphocyte subsets were measured 8 h after OA aerosol challenge in minced and digested lungs. A decrease in percentage of blood and airway Ts, respectively, in test animals was observed vs controls (blood: 6.27 +/- 0.84 vs 32.95 +/- 1.94, P < 0.001); (airway: 5.05 +/- 0.66 vs 24.5 +/- 3.05, P < 0.02). Blood and airway helper T lymphocytes did not differ between test and control animals. The LR was significantly increased in test (22.89 +/- 3.92) vs controls (4.22 +/- 2.18, P < 0.001). Bronchoalveolar lavage macrophages, neutrophils and lymphocytes, and serum OA-specific IgE were also significantly elevated (P < 0.05) in test animals. We conclude that Ts play an important role in attenuating the LR in SD rats.

Transient wheeze. Eosinophilic bronchobronchiolitis in acute eosinophilic pneumonia

The clinicopathologic features of five patients with acute eosinophilic pneumonia who presented with transient wheeze as well as acute onset of high fever, severe hypoxemia, and diffuse pulmonary infiltrates are described. Eosinophilic pneumonia was diagnosed by bronchoalveolar lavage and transbronchial lung biopsy. The illness resolved rapidly with or without corticosteroid therapy. No relapse occurred. To characterize the transient wheeze, a transbronchoscopic bronchial biopsy and pulmonary function tests were performed. Specimens of bronchial wall revealed eosinophil infiltration into the bronchial mucosa. Pulmonary function tests demonstrated reduced diffusing capacity and small airway dysfunction. These findings suggested that eosinophil infiltration into the bronchial mucosa might temporarily cause transient wheeze, different from bronchial asthma, due to small airway dysfunction in acute eosinophilic pneumonia.

Cytologic diagnosis of metastatic epithelioid sarcoma. A cytologic mimic of squamous cell carcinoma

A case of epithelioid sarcoma in a 39-year-old woman who had metastatic lesions in her lung from a primary arm tumor is presented. A review of the literature and analysis of this case did not identify any specific light microscopic or immunohistochemical way to separate definitively the lung cytologic smear in this case from squamous cell carcinoma. The authors believe cytologic smears from epithelioid sarcoma can closely mimic smears from squamous cell carcinoma. Pathologists should be alert to these similarities.

Prednisolone treatment in asthma is associated with modulation of bronchoalveolar lavage cell interleukin-4, interleukin-5, and interferon-gamma cytokine gene expression

Although corticosteroids are effective in improving asthma symptoms and bronchial responsiveness, their mechanism of action is unknown. We examined whether changes in bronchial responsiveness with corticosteroid therapy of asthma are accompanied by a reduction in cytokine gene expression and eosinophil infiltration in the airways. Bronchoalveolar lavage (BAL) was performed in 18 patients with moderate asthma before and after 2 wk of treatment with prednisolone, 0.6 mg/kg/day, or matched placebo in a randomized double-blind parallel group study. Cells were counted in BAL cytocentrifuge preparations, and the numbers of cells expressing cytokine mRNA were assessed by in situ hybridization using 35S-labeled RNA probes. When the actively treated and placebo groups were compared, there was a decrease in airway methacholine responsiveness (p < 0.01) after prednisolone. This was accompanied by a decrease in bronchoalveolar lavage eosinophils (p < 0.05), a reduction in the numbers of BAL cells per 1,000 expressing mRNA for interleukin-4 (IL-4, p < 0.01) and interleukin-5 (IL-5, p < 0.005), and an increase in numbers of cells expressing mRNA for interferon-gamma (p < 0.005). These results are compatible with the hypothesis that the beneficial effects of corticosteroids in asthma may result from modulation of cytokine production, with consequent inhibition of local bronchial eosinophilia.

Fractional analysis of the 120-ml bronchoalveolar lavage. Determination of the best specimen for diagnosis of sarcoidosis

STUDY DESIGN

Bronchoalveolar lavage with seven 20-ml aliquots was performed on 9 patients with sarcoidosis and 11 patients with idiopathic pulmonary fibrosis (IPF). The returns from the first 20-ml aliquot (volume 1), the next 100 ml of bronchoalveolar lavage fluid (volume 2), and the last 20 ml of lavage fluid (volume 3) were analyzed separately for cell content and differential cell counts. The cell content was calculated four different ways, including absolute number of cells per milliliter of return and as a differential cell count using three different denominators. The denominators used were (1) neutrophils, lymphocytes, eosinophils, macrophages, and epithelial cells; (2) neutrophils, lymphocytes, eosinophils, and macrophages; and (3) neutrophils, lymphocytes and eosinophils. The data were analyzed to see what volume and arithmetic expression of cell content provided the best means of distinguishing sarcoidosis from IPF.

RESULTS

The results confirmed a proximal distribution of the first 20-ml aliquot with more bronchial epithelial cells and neutrophils than volumes 2 and 3. There were more macrophages and lymphocytes in volumes 2 and 3 than in volume 1. Volumes 2 and 3 had similar cell content. Sequential fractional analysis showed that the cells in volume 2 and 3 more clearly distinguished sarcoidosis from IPF than the cell content of volume 1.

CONCLUSION

The presence of lymphocytes, and especially a predominance of lymphocytes with the relative absence of neutrophils, correlated best with sarcoidosis. The percentages of differential cell counts proved superior to both the absolute number of neutrophils and of lymphocytes per milliliter of return in distinguishing sarcoidosis from IPF. A percentage differential cell count with a denominator of neutrophils+lymphocytes+eosinophils provided the best means of distinguishing between sarcoidosis and IPF.

Impaired sensorineural function after allergen-induced mediator release

We tested the hypothesis that allergen-induced mediator release augments the magnitude of isocapnic dry gas hyperpnea-induced bronchoconstriction in sensitized guinea pigs. Male Hartley guinea pigs were sensitized by spontaneous inhalation of ovalbumin (OA) aerosol on days 0 and 7 of the study. On day 14, sensitized animals again breathed OA aerosol and were prospectively divided into a group that exhibited labored breathing (LB), presumably reflecting OA-induced inflammatory mediator release, and a group that did not exhibit LB at this time. Control guinea pigs breathed saline aerosol on days 0, 7, and 14. Bronchoalveolar lavage on day 17 disclosed relative eosinophilia in OA+LB, but not in OA-LB, animals. On day 17, the bronchoconstrictor responses to increasing intravenous (i.v.) doses of acetylcholine (ACh), substance P (SP), neurokinin A (NKA), and capsaicin, as well as dry gas hyperpnea, were measured in vivo in animals from each group. Control and OA-LB guinea pigs exhibited similar responses, but OA+LB animals demonstrated augmented bronchoconstriction induced by i.v. administration of ACh, SP, or NKA. However, despite their augmented responsiveness to these exogenous constrictor agonists, OA+LB animals displayed no greater bronchoconstriction after dry gas hyperpnea or i.v. capsaicin administration. It is known that both dry gas hyperpnea and i.v. capsaicin cause bronchoconstriction in guinea pigs by releasing endogenous tachykinins from airway sensory C-fibers. Thus, our results suggest that allergen-induced mediator release impairs endogenous tachykinin release from airway sensory C-fibers in guinea pigs.

Enhanced production of IL-1 receptor antagonist by alveolar macrophages from patients with interstitial lung disease

Alveolar macrophages (AM) produce various inflammatory and immunomodulatory cytokines. The objective of these experiments was to evaluate the production of IL-1ra, a specific receptor antagonist of IL-1, by AM from nonsmoking control subjects (n = 9), smoking control subjects (n = 6), and patients with interstitial lung disease (ILD) (n = 9). IL-1ra protein levels in cultured AM lysates and supernatants were determined by a specific ELISA; relative steady-state IL-1ra mRNA levels were measured using a specific cDNA probe. Before culture the isolated AM from all subject groups contained undetectable IL-1ra mRNA and no IL-1ra protein in the cell lysates as determined by ELISA. AM from nonsmoking control subjects spontaneously produced IL-1ra protein after a 20 h culture in medium, approximately 12 ng/ml with around half in cell lysates. AM from smoking control subjects produced levels of IL-1ra that were similar to the levels in AM from nonsmokers. In contrast, AM from nonsmoking ILD patients (n = 6) produced high levels of IL-1ra spontaneously (approximately 28 ng/ml), with no enhancement observed when cultured on adherent IgG. Interestingly, AM from smoking ILD patients (n = 3) produced lower levels of IL-1ra protein (approximately 11 ng/ml) that were comparable to levels noted in smoking control subjects. AM from all three types of subjects produced decreased amounts of IL-1ra in response to LPS and enhanced amounts in response to GM-CSF. In general, IL-1ra steady-state mRNA levels correlated with protein production.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis

STUDY DESIGN

Between February 1, 1984, and February 1, 1989, fiberoptic bronchoscopy was performed on 2,692 patients, 592 of whom had bronchoalveolar lavage (BAL). One hundred twenty-eight patients with 16 percent or more lymphocytes in BAL fluid (BALF) were selected for further study. The group included 27 patients with sarcoidosis, 28 with nonsarcoidosis interstitial lung disease (ILD), 22 with lung infection (organism isolated), 31 with inflammation (presumed infection, no organism isolated), 14 with neoplasm, and 6 with bronchial hyperreactivity.

METHODS

The percentages of lymphocytes, B lymphocytes, and T lymphocytes, the CD4/CD8 ratio and the percentages of neutrophils and eosinophils were analyzed individually and in combination for discrimination between the sarcoidosis and nonsarcoidosis patients and compared with the diagnostic accuracy of multiple noncaseating granuloma (MNG) on a simultaneous transbronchial biopsy (Tbbx).

RESULTS

Neither the percentages of lymphocytes, T lymphocytes, or B lymphocytes discriminated sarcoidosis from nonsarcoidosis patients. Sarcoidosis patients had higher CD4/CD8 ratios, fewer neutrophils, and 1 percent or less eosinophils in the BAL cell populations. An analysis of CD4/CD8 ratios, and percentages of neutrophils and eosinophils individually revealed that a CD4/CD8 ratio of 4:1 or greater had a positive predictive value of 94 percent in distinguishing sarcoidosis from other ILD but a sensitivity of only 59 percent. The positive predictive value of CD4/CD8 ratio of 4:1 or greater fell to 50 percent in separating sarcoidosis from all other diseases. A CD4/CD8 ratio of less than 1:1 has a 100 percent negative predictive value to exclude the diagnosis of sarcoidosis. Finding 1 percent or less neutrophils in BAL had an 80 percent positive predictive value in distinguishing sarcoidosis from nonsarcoidosis ILD and 51 percent for distinguishing sarcoidosis from all other disease groups. The CD4/CD8 ratio and the percentages of neutrophils and eosinophils also were combined and analyzed for the diagnosis of sarcoidosis.

CONCLUSIONS

Results showed a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils has essentially the same specificity and positive predictive value as MNG on Tbbx in distinguishing sarcoidosis from nonsarcoidosis disease. The combination of finding MNG in a Tbbx specimen plus a BALF CD4/CD8 ratio of 4:1 or greater had a 100 percent positive predictive value in separating sarcoidosis from other ILD and an 81 percent value in separating sarcoidosis from all other disease. Finding MNG in a Tbbx specimen plus a BALF with a CD4/CD8 ratio of 2:1 or greater, 1 percent or less neutrophils, and 1 percent or less eosinophils had a 93 percent positive predictive value in distinguishing sarcoidosis from both nonsarcoidosis ILD and all other diseases.

Responses of horses affected with chronic obstructive pulmonary disease to inhalation challenges with mould antigens

Eight control and 8 asymptomatic COPD-affected horses were given, on separate occasions, inhalation challenges with extracts of Micropolyspora faeni, Aspergillus fumigatus and Thermoactinomyces vulgaris. All horses were also given nebulised phosphate-buffered saline (PBS) challenges and 'natural challenges' (NCs), i.e. exposure to hay and straw, as control challenges. Responses were assessed by clinical, pulmonary mechanics, arterial blood gas tensions, arterial blood pH and bronchoalveolar lavage fluid cytological examinations. PBS challenges had no effect on control or COPD-affected horses, while NC induced COPD only in the COPD-affected horses. Pulmonary disease, similar to naturally occurring COPD, was induced, only in the COPD-affected horses, by M. faeni and A. fumigatus challenges, thus implicating these organisms in the aetiology of equine COPD. The role of T. vulgaris in the aetiology of equine COPD could not, however, be determined because the T. vulgaris challenges, in addition to inducing pulmonary disease in 4 COPD-affected horses, induced pulmonary disease in 2 control horses which had been unaffected by NC. The absence of pulmonary disease in control horses after M. faeni, A. fumigatus and NC challenges suggests that equine COPD is a pulmonary hypersensitivity, rather than a non-specific toxic response.

Bronchoalveolar lavage in rheumatoid arthritis

Bronchoalveolar lavage (BAL) was performed on 70 RA patients, 28 without extra-articular manifestations, nine with pulmonary involvement, 13 with sicca-syndrome, 20 with other extra-articular manifestations such as renal involvement, cutaneous vasculitis and rheumatoid nodules. Fifteen patients without rheumatic or pulmonary disease served as the control group. Compared with the control group RA patients showed a statistically significant increase of lymphocytes, especially of activated (DR+)T(CD3+)-helper (CD4+) cells, resulting in a significantly diminished percentage of alveolar macrophages, B(CD21+)-lymphocytes, T-suppressor (CD8+) cells and an increased CD4/CD8 ratio. This cell distribution pattern was more pronounced in RA patients with lung involvement with significant differences to the other RA patients with regard to lymphocytes, DR positive cells and CD4 positive/DR positive cells. It is concluded that these results indicate an altered balance of immunocompetent cells not only in the joints but also in the lung. The changes are more distinct if local manifestations can be diagnosed clinically.

Relative release of interleukin-1 beta and interleukin-1 receptor antagonist by alveolar macrophages. A study in asbestos-induced lung disease, sarcoidosis, and idiopathic pulmonary fibrosis

We examined the influence of untreated interstitial lung disease (ILD) on the in vitro release of interleukin-1 beta (IL-1 beta) and interleukin-1 receptor antagonist (IL-Ira) from alveolar macrophages (AM); AM were harvested from normal volunteers, ILD patients, and patients with asbestos-related pleural disease but no ILD. AM were cultured for 24 h and assays for IL-1 beta and IL-1ra were done using sensitive and specific enzyme-linked immunosorbent assay. A greater amount of IL-1 beta was detected in AM supernatants from asbestosis, sarcoidosis, and IPF patients than in those from normal subjects. The IL-1 beta:IL-1ra ratio (IL-1 beta activity index [IL-1AI]) was significantly lower in supernatants of normal macrophages compared with macrophage supernatants from individuals with ILD. The IL-1AI correlated with bronchoalveolar lavage cellularity, a marker of disease activity. Current smoking was associated with lower IL-1 beta and IL-1ra release in ILD. The IL-1AI is a convenient method for comparison of IL-1 beta activity between patient populations.

Amount of Pneumocystis carinii and degree of acute lung inflammation in HIV-associated P carinii pneumonia

Correlations between semiquantitative amounts of Pneumocystis carinii (PC), the degree of inflammation, and the severity of pneumonia were analyzed in 58 patients with PC pneumonia (PCP). Material from both transbronchial biopsies (TBBs; n = 39) and bronchoalveolar lavage fluid (BALF; n = 57) was examined. In the TBB the amount of PC correlated strongly with overall inflammation in the interstitium (Kendall correlation coefficient [Kcc] = 0.59; p < 0.0001), type 2 pneumocyte proliferation, and edema formation. The amount of PC in the TBB also correlated with interstitial accumulation of neutrophils (Kcc = 0.54; p = 0.0001), lymphocytes, and macrophages. In BALF the amount of PC correlated with edema formation and type 2 pneumocyte proliferation in the TBB but not with the percentage of neutrophils, lymphocytes, or macrophages in BALF. The amount of PC in the BALF and the percentage of neutrophils in the BALF correlated significantly with Po2 and the serum lactate dehydrogenase (LDH) level. Neither short-term nor long-term survival was affected by the amount of PC, inflammatory markers in the TBB, inflammatory cells in BALF, Po2, or the serum LDH levels. In conclusion, the amount of PC is associated with the extent of the acute inflammatory reaction in the lung in PCP associated with human immunodeficiency virus (HIV).

Pathology of asthma and its clinical implications

Although detailed histopathologic studies have described the inflammatory processes present in fatal asthma, until recently the pathology of less severe forms of the disease has been less well understood. Now a series of important studies has extended our understanding of the pathophysiology of mild asthma. Studies that examine sputum or fluid obtained by bronchoalveolar lavage from mildly asthmatic subjects revealed findings consistent with an active inflammatory process within the airways. The histopathologic examination of endobronchial biopsy specimens from stable asthmatic patients has shown that inflammatory cell infiltration of the mucosa is a distinctive feature of mildly asthmatic subjects requiring only intermittent inhaled beta-agonist therapy. These studies have also shown that marked tissue disruption may occur early in the natural history of mild asthma. These investigations have demonstrated that asthma is a disease characterized by acute and chronic inflammatory changes within the airways and that in many respects the histopathologic features of mild allergic asthma are similar to those observed in fatal asthma. The therapeutic implications of these findings are that management of mild asthma should be directed toward resolving this inflammatory process. There is now sufficient evidence to suggest that anti-inflammatory drugs such as cromolyn sodium, inhaled corticosteroids, and nedocromil sodium be used earlier in the course of the disease and that the use of these therapeutic agents should not be limited to patients with severe forms of asthma. This may be particularly important in view of the increasing awareness of the potential problems associated with the overreliance on beta-agonist therapy in patients with asthma.

Pulmonary inflammatory cells in ventilated preterm infants: effect of surfactant treatment

The aim of this study was to determine the effect of surfactant treatment on the number and distribution of inflammatory cells in bronchoalveolar lavage fluid (BALF) from mechanically ventilated preterm infants over the first week of life in relation to the subsequent development of chronic lung disease (CLD). The study included 25 babies who received surfactant on clinical grounds and 29 babies of similar severity who did not. BALF was collected on days 1, 3, 5, and 7 after birth. Cell counts were performed and differentials were calculated on 300 cells. CLD was equally common in both treatment groups. Of the 54 infants, 29 (53%) who developed CLD had a higher incidence of patent ductus arteriosus and air leak and needed a higher concentration of inspired oxygen on the fifth and seventh days of life. Babies who developed CLD had more polymorphonuclear leucocytes and fewer macrophages on days 5 and 7 than those who recovered. Surfactant treatment was associated with a higher total white cell count on day 3. Between days 3 and 7, macrophage numbers were higher in surfactant treated babies, whatever the pulmonary outcome. This data suggests that CLD was associated with persistence of high numbers of polymorphonuclear leucocytes in BALF at the end of the first week. Surfactant treatment caused a persistent increase in macrophage numbers. The association between persistent neutrophilia and CLD was unaffected by surfactant treatment.

Evaluation of local endobronchial antigen challenges in the investigation of equine chronic obstructive pulmonary disease

Local transendoscopic endobronchial antigen challenge, which has proved to be a valuable clinical and research technique in the study of human pulmonary hypersensitivity, was evaluated in control and asymptomatic COPD--affected horses. Transendoscopic endobronchial challenges with phosphate-buffered saline (PBS), Micropolyspora faeni extract at 60 and 600 micrograms/ml and mouldy hay extract elicited neutrophilic airway inflammatory responses in control (N = 5-7) and asymptomatic COPD-affected (N = 5-7) horses, as determined by cytological examinations of bronchoalveolar lavage fluid (BALF) harvested from the challenged lung segments. Endobronchial challenges with 600 micrograms M. faeni extract/ml induced a significant BALF neutrophilia only in horses with asymptomatic COPD, when compared with PBS challenges. However, as the BALF neutrophil ratios of COPD-affected horses after this M. faeni challenge did not differ significantly from those of control horses, this finding has little clinical diagnostic value. The BALF neutrophilia induced in control and asymptomatic COPD-affected horses by 60 micrograms M. faeni extract/ml and mouldy hay extract challenges was not significantly different from that induced by PBS challenge. Endoscopically visible bronchial changes were observed in some of the control and COPD-affected horses within 5 mins and at 5 h after PBS, M. faeni and mouldy hay extract challenges. We conclude that this technique is of no value in the investigation of equine COPD.

Lung fibrosis in hypersensitivity pneumonitis. Association with CD4+ but not CD8+ cell dominant alveolitis and insidious onset

Seventeen cases of hypersensitivity pneumonitis (HP) at a symptomatic phase were categorized into two groups based on computed tomographic (CT) findings and histologic features of transbronchial lung biopsy specimens, HP accompanied by lung fibrosis (fibrosis group), and HP unaccompanied by lung fibrosis (nonfibrosis group). The fibrosis group comprised bird fancier's lung and HP of unknown etiology, whereas the nonfibrosis group mainly comprised summer-type HP. Comparison of results of pulmonary function tests between these two groups confirmed a restrictive impairment in the fibrosis group. Analyses of cellular components of bronchoalveolar lavage (BAL) fluids revealed lymphocytes, especially CD8+ T lymphocytes, were significantly increased in the nonfibrosis group in comparison with the fibrosis group, whereas CD4+ T cells were increased to the same level in the both groups. Analyses of the onset of disease showed that acute onset was observed mainly in nonfibrosis group and strongly correlated with increased CD8+ T lymphocytes in BAL fluids, while insidious onset was related to lung fibrosis and relatively increased CD4+ T lymphocytes in BAL fluids. These findings raise the possibility that highly elevated CD8+ T cells might have a protective effect on pulmonary fibrosis or that relatively increased CD4+ T cells might play an important role in the pathogenesis of pulmonary fibrosis of HP at the chronic phase.

Pulmonary involvement in human T-cell lymphotropic virus type-I uveitis: T-lymphocytosis and high proviral DNA load in bronchoalveolar lavage fluid

The ocular manifestation of human T-cell lymphotropic virus type I (HTLV-I) infection has been recognized as a new clinical entity termed HTLV-I uveitis. In order to determine whether HTLV-I uveitis is associated with lymphocyte alveolitis, bronchoalveolar lavage (BAL) was carried out in 11 patients with HTLV-I uveitis, five asymptomatic HTLV-I carriers, 11 HTLV-I-negative patients with ocular sarcoidosis, and nine normal control subjects seronegative for HTLV-I. Six of the 11 patients with HTLV-I uveitis showed increased total cell counts, and T-lymphocytosis in BAL fluid. CD4+/CD8+ ratios of T-lymphocytes were decreased in three of these patients, and normal in three other patients. Such abnormalities of the lung were not found in asymptomatic HTLV-I carriers, and in normal control subjects. BAL findings in HTLV-I uveitis differed from those of patients with sarcoidosis in terms of the lymphocytic component. Interestingly, it was found that there was an increase of HTLV-I proviral deoxyribonucleic acid (DNA) load in peripheral blood mononuclear cells (PBMC) from seven patients with HTLV-I uveitis, and in the BAL cells from four patients with pulmonary involvement. These results provide further evidence in terms of HTLV-I tropism for the lung, and suggest that a systemic and local increase of HTLV-I proviral DNA load plays an important role in the pathogenesis of lymphocyte alveolitis in patients with HTLV-I uveitis.

Inflammatory response of the lung to tungsten particles: an experimental study in mice submitted to intratracheal instillation of a calcium tungstate powder

Tungsten has been implicated as a cause of a severe form of pneumoconiosis in humans, the so-called "hard metal" lung disease. We have investigated the effect of intratracheal instillation of a powder of calcium tungstate on the pulmonary tissue of CD-1 mice. The tungsten-induced alterations were studied using 3 microanatomical methods: cytologic study of exudates obtained by bronchoalveolar lavage (BAL); histologic examination of paraffin-embedded sections of the lung; and scanning electron microscopic (SEM) examination of lung samples using x-ray microanalysis to detect tungsten in situ. The animals were sacrificed 1, 3, 7, 14 and 21 days after a single intratracheal instillation of 250 micrograms calcium tungstate particles suspended in 100 microliters of saline. We found that the metal particles induced a marked inflammatory response in the bronchoalveolar space characterized by a biphasic attraction of leukocytes with cellular peaks observed at day 1 and 14. More than 50% of the BAL macrophages showed ingested tungsten. In the lung parenchyma, the inflammatory infiltrates were predominantly located at the periphery of the bronchiolar walls. From 7 days on after the tungsten deposition, large inflammatory exudates were seen invading focal areas of the alveolar domain of the lung. SEM views revealed that the tungsten particles could be inside alveolar macrophages, in cells making up the alveolar wall, or inside periacinar lymphatics. Our data document that tungsten particles cause a marked inflammatory response in the lung tissue and that the leukocyte exudates may invade alveolar areas of the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoalveolar lavage and lung biopsy in rheumatoid arthritis. In vivo effects of disease modifying antirheumatic drugs

Bronchoalveolar lavage (BAL) and histology of transbronchial forceps biopsy was performed in 59 patients with rheumatoid arthritis (RA) to evaluate the in vivo effects of disease modifying drugs (DMARD). All patients had no clinical pulmonary symptoms and there was no evidence of drug induced alveolitis. Patients were divided into 5 subgroups according to drug treatment: 9 patients taking chloroquine, 15 patients gold, 8 patients penicillamine, 8 patients methotrexate (MTX) and 19 patients not taking DMARD. Duration of DMARD regimen was more than 3 months. No patient was treated with corticosteroids. BAL results revealed an increased percentage of lymphocytes and a diminished proportion of alveolar macrophages in patients treated with gold, penicillamine, MTX and no DMARD. In contrast, patients receiving chloroquine had a normal distribution of lymphocytes and macrophages as seen in a control group of 15 persons. Patients taking MTX showed a normal distribution of T and B lymphocytes and DR positive cells, whereas patients receiving chloroquine, gold, or penicillamine had an elevated proportion of T lymphocytes and DR positive cells and a diminished percentage of B lymphocytes. The latter was also observed in patients not taking DMARD. The percentage of natural killer cells was significantly elevated only in the penicillamine group. Patients receiving gold had higher absolute values of CD3, CD4 and DR positive cells. Abnormal lung histology was associated with an increased percentage of lymphocytes and with higher DR positive cells in BAL. Patients not receiving DMARD had a significantly higher percentage (42.1%) of abnormal histologic features of lung tissue than patients receiving DMARD (17.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of flexible fiberoptic bronchoscopy under local anesthesia in infants]

From October 1991 through April 1992, 16 infants aged 5 to 25 months (mean age 14.3 months) underwent bronchoscopy with a flexible fiberoptic bronchoscope, under local anesthesia. The technique is described in detail. Reasons for bronchoscopy included recurrent or persistent pneumonia (n = 4), persistent atelectasia (n = 4), lymphadenopathy and/or airway compression (n = 2), suspected foreign body (n = 2), bronchoalveolar lavage to investigate diffuse interstitial lung disease (n = 2), and severe recurrent wheezing (n = 2). The procedure established the accurate diagnosis in 14 cases. Adverse events (32%) were minor (transient hypoxia, n = 3; moderate fever, n = 1; and laryngospasm, n = 1) and resolved completely. Flexible fiberoptic bronchoscopy under local anesthesia is a simple procedure which is safe in patients under 30 months of age when performed by a experienced operator in an adequate facility. This method is useful for the diagnosis and/or treatment of a broad spectrum of conditions.

Aluminium inhalation in sheep silicosis

In prior studies, we and others have documented a significant reduction by surface chemistry modification in the biological activity of quartz. We further documented that aluminium lactate inhalation one month after quartz exposure significantly suppressed the silica-induced alveolitis, reduced the pathological process and decreased the retention of quartz in the lung tissue. In the present study, we evaluated the efficacy of aluminium inhalation in altering the silicosis process after disease was recognized by standard chest radiography. Twenty-four sheep were enrolled in the study. The 14 silica exposed sheep had an abnormal chest radiograph of the ILO category 1 or above after 3 years of 100 mg Minusil-5 in 100-ml saline intratracheal injections. Ten control sheep were exposed to saline intratracheal injections. All sheep were evaluated at 3-month intervals by chest radiography, lung function and lung lavage. At month 36 of the study, all 14 sheep had an abnormal chest radiograph while the radiographs of controls remained normal. The sheep with silicosis had significantly reduced lung functions and increased cellularity, phospholipids and hyaluronan. These changes persisted during the next 12 months without exposure or treatment. At month 48 and at monthly intervals after, for 12 months, aerosol inhalations were carried out with saline alone for control and seven silicotic sheep and with 100 mg of aluminium lactate in 10 ml saline generated with a Bird Mark 8 pressure ventilator for the other seven silicotic sheep. All sheep were evaluated at 3-month intervals by chest radiography, lung function and lung lavage.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous zymosan-A challenge induces an alveolar inflammatory response

The purpose of this study was to evaluate the ability of intravenous zymosan-A (ZyA) challenge to induce an alveolar inflammatory response as indicated by inflammatory changes among lung lavage cells. The organ distribution of 1 mg of [51Cr]ZyA revealed that immediately following intravenous challenge of female ICR mice approximately 81% of the total cpm injected was associated with pulmonary tissue. Approximately 15% of the injected cpm was associated with the peripheral blood, liver, and spleen. ZyA translocated from the vascular compartment into pulmonary alveoli and was detected within polymorphonuclear neutrophils (PMN) and alveolar macrophages (AM) 18 h after intravenous challenge. PMN numbers among lung lavage cells increased beginning one day after challenge to a peak of approximately 5 x 10(5) PMNs by day 3 after challenge. The PMN response subsided by day 5 after challenge. There was no significant increase in the numbers of AM during the first week after intravenous ZyA; however, the number of AM increased from approximately 5 x 10(5) AM on day 1 after challenge to approximately 1.1 x 10(6) AM by day 5 after challenge. Within 24 h of intravenous ZyA, the number of AM in S phase of the cell cycle increased from approximately 2.5 x 10(4) AM one day after challenge to 1.1 x 10(5) AM in S phase five days after challenge. The data suggest that intravenous ZyA localized within pulmonary tissue immediately following intravenous challenge and translocated into the alveolar compartment where ZyA particles were found within phagocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoalveolar lavage and transbronchial lung biopsy during acute rejection and infection in heart-lung transplant patients. Studies of cell counts, lymphocyte phenotypes, and expression of HLA-DR and interleukin-2 receptor

The total and differential cell counts of 135 bronchoalveolar lavages (BAL) in 48 heart-lung transplant (HLT) patients were compared with the histologic findings in concurrent transbronchial lung biopsies (TBBs). Counts of CD3+, CD4+, and CD8+ lymphocytes were recorded, and a semiquantitative assessment of HLA-DR and interleukin-2 receptor (IL-2R) expression was made on 29 occasions. There were five diagnostic categories: normal (n = 8), acute rejection (ALR) (n = 57), treated rejection (TR) (n = 19), infection (INF) (n = 24), and chronic rejection (CR) (n = 24). Total cell counts in INF were significantly higher than counts in all the other diagnostic groups. The highest BAL lymphocyte counts, significantly higher than in INF, were found in ALR because of increased CD8+ cells, exceeding 15% in 13 of 57 BALs. TBBs in ALR by contrast showed significantly increased numbers of both CD8+ and CD4+ cells. High dose corticosteroid treatment of ALR caused a fall in cellularity of BAL and TBB specimens but not always to values seen when patients were well. During INF and CR, significantly increased numbers of PMNs were seen in the BAL. HLA-DR and IL-2R expression was enhanced in cells of BAL and TBB in all complications. BAL can only supplement at present histologic examination of TBB in the diagnosis of complications after HLT.

Pleuropulmonary abnormalities in primary Sjögren's syndrome

Sixteen patients with primary Sjögren's syndrome (1 degree SS) who complained of dyspnea were investigated with high resolution computerized tomography of the thorax, bronchoalveolar lavage, and transbronchial biopsy. Six patients had evidence of interstitial fibrosis, 5 had a peribronchiolar lymphocytic infiltration and 3 had pleural thickening. We conclude that significant pulmonary disease is not uncommon in patients with 1 degree SS.

Increased pulmonary response to inhaled endotoxin in lactating rats

An important aspect of risk assessment is identification of subpopulations particularly susceptible to the effects of inhaled pollutants. The present study examined whether female rats were more sensitive during lactation to the acute pulmonary injury produced by inhaled endotoxin. Lactating and age-matched virgin female rats were exposed to aerosols of saline or endotoxin for 3 h and lavaged at 24 h after exposure. No significant differences in lactate dehydrogenase, beta-glucuronidase, total protein, and total cell and PMN counts were observed between virgin and lactating rats after exposure to saline. Each marker of pulmonary injury except beta-glucuronidase was 1.5- to 3-fold greater in lactating than in virgin female rats exposed to 29.6 micrograms/m3 endotoxin. PMNs (6-fold), total cell counts, and protein were also significantly increased (p < 0.05) in lactating rats exposed to 1.3 micrograms/m3 endotoxin, a concentration reported to occur in a number of agricultural settings. These results demonstrate that the physiologic state of lactation is associated with an increased sensitivity to the acute pulmonary injury produced by inhaled endotoxin and are consistent with previous work demonstrating a similar increased sensitivity to ozone exposure. The possibility of a similar pattern of enhanced response in analogous groups of humans merits examination.

Distribution of asbestos bodies in the human lung as determined by bronchoalveolar lavage

Asbestos-related lung diseases tend to have distinct local distributions, for example, asbestosis first appears and tends to be more severe in the peripheral parts of the lower lung zones. The risk for asbestosis is related to the total asbestos burden of the lung. This suggests that the lower lobes in asbestos-exposed individuals may contain more asbestos than the other lobes. To test whether such topographic differences exist, we compared the number of retrieved asbestos bodies (AB) per ml BAL fluid in three groups of occupationally asbestos-exposed subjects who underwent BAL at different sampling sites. In Group 1 (n = 24) we performed BAL at three sites, namely in a segment of the right upper, right middle, and right lower lobe, to evaluate differences in asbestos body burden from lung apex to basis. There was a distinct increase in BAL asbestos body concentrations from the upper (21.2 +/- 9.1 AB/ml BAL fluid) to the middle (30.4 +/- 12.8 AB/ml BAL fluid) and to the lower lobe (56.0 +/- 20.2 AB/ml BAL fluid), all differences being significant (p < 0.01). In Group 2 (n = 40), we found good interlobar correlations for asbestos body counts between the right middle lobe (21.0 +/- 5.8 AB/ml BAL fluid) and the lingula (22.4 +/- 5.9 AB/ml BAL fluid) (r = 0.941, p < 0.001) and, in Group 3 (n = 15), between the ventral basal segment of the right (41.2 +/- 13.6 AB/ml BAL fluid) and left lung (39.0 +/- 13.6 AB/ml BAL fluid) (r = 0.966, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of biochemical and cytological profile of bronchoalveolar lavage constituents in rats following split-dose multiple inhalation exposure to methyl isocyanate

1. Studies were carried out to explore the acute pulmonary effects of equal, split-dose, multiple inhalation exposures of rats to methyl isocyanate (MIC), (0.32 mg l-1, 8 min x 10 exposures) as reflected by alterations in bronchoalveolar lavage fluid (BALF) constituents and to evaluate recovery, if any, following survival in a MIC-free environment, 10 d after the last MIC exposure. 2. In the BALF of MIC-exposed rats, there was an increase in the total number of cells and the number of cells showing enhanced dye uptake and reduction of nitroblue tetrazolium chloride. The cell-free BALF showed increases in total protein, sialic acids and lactic acid contents and lactate dehydrogenase activity. 3. In rats exposed to MIC and sacrificed 10 d after survival in a MIC-free environment, there was a reduction in the cellular and biochemical constituents of BALF. The phagocytic potential of macrophages was, however, also decreased under this regime.

Effect of stabling on bronchoalveolar cells obtained from normal and COPD horses

Bronchoalveolar lavages (BAL) were performed before and after 3 weeks of housing in 5 horses suffering from COPD and 5 normal horses. In the two groups, the total number of cells recovered remained unchanged after stabling. The most common cell populations in BAL fluid of control animals were alveolar macrophages (46.4%) and lymphocytes (44.9%). The percentage of neutrophils increased after stabling from 8.7% to 27.6%. In COPD horses, lymphocytes predominated (40.7%) in animals at pasture with neutrophils increasing from 29.4% to 71.6% after stabling. After fractionation by Percoll density gradient, alveolar macrophages and neutrophils from normal and COPD horses had a similar density distribution. After stabling, these cells from normal horses were increased in the low density layers, while those from COPD horses were predominantly in the hyperdense layers. Therefore, BAL cells obtained from COPD animals at pasture and after stabling differ from those of control horses in the same environment, not only in their populations but also in their buoyant densities. These differences could be related to different states of cellular activation and perhaps be responsible for disease activity in the COPD horses.

Cytologic diagnosis of metastatic malignant melanoma of the lung in sputum and bronchial washings. A case report

A 60-year-old woman with a fever, productive cough, anorexia, weight loss and past history of malignant melanoma of the finger proved to have metastatic melanoma in both lungs on cytologic study of sputum and bronchial washings. The literature in English over 40 years (1952-1992) gives only a few hints about the value of cytologic diagnosis of metastatic malignant melanoma of the lung. Cytologic features include a variable amount of melanin pigment, isolated or loosely cohesive groups of round to oval cells with eccentric nuclei, regular nuclear outline, anisocytosis, binucleation and multinucleation, fine chromatin pattern and prominent nucleoli.

Transbronchial lung biopsy in the diagnosis of suspected ocular sarcoidosis

We conducted clinical research using transbronchial lung biopsy in 60 patients with suspected ocular sarcoidosis who showed no bilateral hilar lymphadenopathy and sparse contributory evidence for sarcoidosis. The patients had a combination of granulomatous iritis with mutton-fat keratic precipitates or iris nodules, trabecular nodules, tent-like peripheral anterior synechiae, snowball or string-of-pearls vitreous opacities, retinal perivasculitis, and spotty retinochoroidal exudates. The transbronchial lung biopsy specimen showed noncaseating epithelioid granuloma in 37 patients (61.7%); these patients were diagnosed as having sarcoidosis. Bronchoalveolar lavage showed a high percentage of patients with an increased lymphocyte fraction among those with positive transbronchial lung biopsy results. The present results may serve as a basis for a clinical diagnosis of sarcoidosis in patients with suspected sarcoidosis without apparent extraocular manifestations.

Whole-body hyperthermia combined with hyperfractionated irradiation of the thorax in dog: acute physiological response

Whole-body hyperthermia has potential as an adjuvant treatment with chemotherapy and radiation therapy for diseases such as lung cancer which require both local and systemic control. The acute toxicity of whole-body hyperthermia combined with whole-thorax irradiation was studied in dogs. Twenty-eight dogs received three 2-h whole-body hyperthermia (WBH) treatments at 42.0 degrees C deep rectal temperature. Twenty-four of these dogs were also randomized to receive radiation doses of 18, 22.5, 27, 31.5, 40.5 or 45 Gy. Irradiation was given in 1.5 Gy fractions over 6 weeks. Three WBH treatments were given to 28 dogs with all dogs surviving treatment. WBH was given on days 1, 22 and 40 of the 6-week interval. Thirty-one dogs received radiation doses of 18-49.5 Gy without WBH. Deep rectal temperature was maintained at 41.9 +/- 0.3 degrees C over 2 h with an average of 20 min outside the chamber for irradiation. Two dogs required intervention with emergency medications during WBH treatment. One of the two dogs developed permanent neurological injury. Continuous physiological monitoring was necessary for successful WBH. WBH plus thoracic irradiation was well tolerated. All dogs survived all treatments. A significant but transient increase in peripheral blood leucocytes and a decrease in platelet counts occurred after each WBH treatment. The addition of thoracic irradiation up to 45 Gy in 1.5 Gy fractions did not appear to alter the acute toxicity of WBH with the exception of an increase in the protein content of lung lavage fluids. In conclusion, multiple WBH treatments of 2 h at a target temperature of 42 degrees C in addition to thoracic irradiation up to 45 Gy in 1.5 Gy fractions was administered with only mild acute toxicities occurring. Core temperature could be maintained for up to 20 min outside of the WBH chamber which allowed irradiation to be given concurrently with hyperthermia at a core temperature of 42 degrees C +/- 0.1 degree C.

Controlled short-time terpene exposure induces an increase of the macrophages and the mast cells in bronchoalveolar lavage fluid

Eight healthy nonsmoking volunteers underwent terpene exposure (450 mg/m3 air) on 4 different occasions within a 2 week period. Total exposure time was 12 hours. Before and after the sequences of exposure, bronchoalveolar lavage was performed. Twenty hours after the exposure there was a significant (p < 0.05) increase of the alveolar cell concentration (median pre-exposure value 76 x 10(6) cells/L, post-exposure value 126 x 10(6) cells/L), predominantly due to an increment of the macrophages (from 72 x 10(6) cells/L to 121 x 10(6) cells/L). The mast cells also increased from 1/10 to 5/10 visual fields. No elevated concentrations of albumin, fibronectin, hyaluronan (hyaluronic acid), and tryptase were observed. We conclude that terpene exposure, in a concentration regarded as moderate, induces an acute alveolar cellular reaction in healthy subjects.

Pulmonary toxicity of deferoxamine in iron-poisoned mice

Previously we have shown that a group of patients treated for iron overdose with prolonged deferoxamine (DFO) infusion died of adult respiratory distress syndrome (ARDS). We now describe a model to investigate the mechanism of this pulmonary toxicity. Mice treated with 1 oral dose of iron (Fe) and then multiple injections of DFO, or with the chelated product ferrioxamine alone, did not develop lung lesions, even at doses which induced mortality. To potentiate any possible free radical reaction, other groups of mice were treated similarly while exposed to 75-80% O2 over a 4-day period. Ten of 12 mice receiving 0.75 mg Fe and then DFO (10 mg, 4 times/day for 4 days) with hyperoxia died suddenly. At autopsy the lungs were dark red and solid; sections showed hyaline membranes and alveolar exudates of edema, fibrin, and PMN. Electron microscopy showed massive destruction of the alveolar epithelium; using cerium chloride, a free radical reaction product was demonstrated at the alveolar surface. Lung lavage fluid contained 10-12 x normal levels of protein when the Fe-DFO-O2 group was compared to air or O2 controls. Mice receiving DFO or Fe, plus O2, showed only slight injury and a small increase in alveolar protein. The results indicate that Fe plus DFO generates free radicals in the lung, a reaction potentiated by hyperoxia to produce an ARDS-like picture. This suggests that the pulmonary toxicity of DFO in iron-poisoned patients is due to its prooxidant activity resulting in free radical destruction of the airblood barrier.

Cyclophosphamide and low-dose prednisone therapy in patients with systemic sclerosis (scleroderma) with interstitial lung disease

Fourteen patients with systemic sclerosis (SSc, scleroderma) and interstitial lung disease were treated with oral cyclophosphamide (1-2 mg/kg/day) and low dose prednisone (< 10 mg/day). There was a significant improvement in FVC after 6 months compared to entry values (2.21 +/- 0.19 l vs. 2.03 +/- 0.15 l, p < 0.02). Improvement was maintained at 12 months (2.27 +/- 0.27 l, p < 0.05) and 18-24 months (2.60 +/- 0.28 l, p < 0.001). In 12 cases followed for 18-24 months, FVC was stable or improved. No significant improvement or decline was noted for the DLCO. Side effects included cytopenia (2), infection (1), and hemorrhagic cystitis (2), and one possible related malignancy. A controlled prospective trial of cyclophosphamide is warranted in patients with SSc and active interstitial lung disease.

Peripolesis in alveolar sarcoidosis

We observed that in bronchoalveolar lavages (BAL) of patients with active sarcoidosis (SARC) a mononuclear cell infiltrate is present that often contains clusters consisting of lymphocytes adhering to a macrophage. In order to investigate what kind of cellular interactions are involved in such a process, cell suspensions obtained from BAL of patients with SARC or extrinsic allergic alveolitis (EAA) were cultured for 1 to 2 days, during which time lapse cinematography was applied. We were able to show that such clusters consist of lymphocytes gathered around a macrophage. This is known as peripolesis. Peripolesis, as observed in our BAL, could last for some minutes or for some hours during which time a number of lymphocytes were moving around a single alveolar macrophage, without losing contact with the macrophage. Short interactions were mostly observed in EAA, whereas SARC was characterized by long periods of lymphocyte-macrophage cooperation. We also found a correlation between the time-dependent peripolesis t > 30 min/t < 30 min and the CD4/CD8 ratio. Although the precise mechanisms of peripolesis are not well understood, some interactions between lymphocytes and macrophages have now become more comprehensive.

Epithelial-fibroblast interactions in bleomycin-induced lung injury and repair

Intercellular communication between epithelial cells and fibroblasts of the alveolar wall contributes to regulatory control of each cell type. We examined whether lung injury and subsequent fibrosis are associated with disturbance of this mutual control system. Rats received bleomycin intratracheally, and after 10 days, when acute epithelial injury occurs, and at 6 weeks, when repair with fibrosis is found, pure populations of type 2 epithelial cells and lung fibroblasts were prepared to study interactions with respect to growth control. Epithelial cells were cultured alone, on a permeable filter over fibroblasts, and in co-culture with fibroblasts. The results showed that the low growth rate of normal epithelial cells increased when cells were exposed to fibroblast supernatants. This effect was also seen using cells from the 10-day bleomycin group, but it was diminished in the group treated for 6 weeks. However, epithelial cells from exposed or control rats did not show increased DNA synthesis when grown in contact with fibroblasts in co-culture. In contrast, fibroblast growth was inhibited when exposed to epithelial cell secretions in control cultures and when using cells from the 10-day bleomycin group. No inhibition of fibroblast growth by epithelial cells was found using cells from the fibrotic lungs. These results suggest that after lung injury by bleomycin, a fibroblast-secreted factor promotes epithelial growth; however, during repair, regenerating epithelial cells lose the ability to inhibit fibro-blast proliferation. These local changes in cellular control at the alveolar wall may be sufficient to produce pulmonary fibrosis.

The diagnosis of Pneumocystis carinii pneumonia by cytologic evaluation of Papanicolaou and Leishman-stained bronchoalveolar specimens in patients with the acquired immunodeficiency syndrome

The presence of foamy alveolar casts or flocculent material in Papanicolaou and Leishman-stained smears of bronchoalveolar lavage (BAL) fluid is said to be indicative of infection with Pneumocystis carinii. We have investigated the sensitivity and specificity of this method of diagnosing pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Patients (n = 114) with diffuse lung infiltrates were submitted to fibreoptic bronchoscopy and BAL. Seventy of them were patients with AIDS. The other 44 individuals were not infected by the human immunodeficiency virus (HIV). Pneumocystis carinii organisms were identified on Grocott's methenamine silver (GMS)-stained BAL smears in 30 patients with AIDS. Flocculent material was present in the Papanicolaou and Leishman-stained smears from all of these cases. Conversely, P. carinii were not seen on GMS-stained smears in the remaining 84 individuals with or without AIDS. No flocculent material was observed in Papanicolaou or Leishman-stained smears in these 84 patients. We concluded that the presence of flocculent material in Papanicolaou or Leishman-stained smears of BAL fluid is indicative of P. carinii pneumonia in patients with AIDS.

Rapid diagnosis of cytomegalovirus pneumonia in marrow transplant recipients by bronchoalveolar lavage using the polymerase chain reaction, virus culture, and the direct immunostaining of alveolar cells

The objective was to compare the use of the polymerase chain reaction (PCR), virus culture, and immunostaining of alveolar cells used alone and in combination as diagnostic methods for the rapid diagnosis of cytomegalovirus (CMV) pneumonia in marrow transplant recipients. Seventy-five marrow transplant recipients with clinical and radiological evidence of pneumonitis were used as subjects. Bronchoalveolar lavage was performed on all patients to obtain material for conventional and/or rapid CMV culture, immunostaining of alveolar cells with monoclonal antibodies (MoAbs), and amplification of CMV-DNA by PCR. Assay results were then prospectively correlated with clinical outcome. Seven of the 75 patients (9.3%) had CMV pneumonitis and 6 patients (8%) had CMV infection without pneumonia. PCR is the most sensitive assay for the detection of CMV in bronchoalveolar lavage fluid. For the diagnosis of CMV pneumonitis, the sensitivity of alveolar cell immunostaining and PCR were both 100%. The sensitivity of virus culture was 85.7%. The positive predictive value for each test, used alone, for the identification of CMV pneumonitis was low. However, when the result of the PCR assay was assessed in combination with CMV immunostaining of alveolar cells, the sensitivity, specificity, positive, and negative predictive value of this strategy was 100%. The concomitant use of PCR and the rapid immunostaining of alveolar cells for CMV has facilitated the development of a sensitive and specific diagnostic algorithm for the detection and early treatment of CMV pneumonitis in transplant recipients.

Acrolein increases airway sensitivity to substance P and decreases NEP activity in guinea pigs

The effects of acrolein exposure on airway responses to intravenous substance P were determined in guinea pigs exposed to vehicle or 1.6 ppm acrolein for 7.5 h on 2 consecutive days and examined 1, 4, 8, 15, and 28 days after exposure by use of pulmonary mechanics and bronchoalveolar lavage (BAL). Lung, trachea, liver, and BAL fluid were also assayed for neutral endopeptidase (NEP) activity 1, 7, and 28 days after exposure. Pulmonary inflammation and epithelial damage were prominent 1 day after acrolein exposure. NEP activity was decreased in the lungs, trachea, and liver 1 and 7 days after acrolein. Twenty-eight days after exposure, NEP activity in the lungs and liver was not significantly different in vehicle- and acrolein-exposed guinea pigs but was still reduced in tracheal tissue. The BAL NEP activity in acrolein-exposed guinea pigs was approximately twice that of vehicle control guinea pigs at all three time points. Acrolein caused a prolonged increase in airway sensitivity to substance P. Experiments performed in the presence of thiorphan suggested that the acrolein-induced reduction in NEP may contribute to increased airway sensitivity to aerosolized substance P, but the increase in airway sensitivity to intravenous substance P may occur by additional mechanisms.

A study of monokine release and natural killer activity in the bronchoalveolar lavage of subjects with farmer's lung

We examined the interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF alpha) releasability of alveolar macrophages and the natural killer (NK) cell activity in the bronchoalveolar lavage (BAL) cells of 11 patients with Farmer's lung at different stages of the disease. Although there were some variations in the levels of monokine release, macrophages of patients with acute disease secreted significantly higher spontaneous levels of TNF alpha than did a nonfarming control group (p = 0.0002). Conversely, TNF alpha release stimulated by bacterial lipopolysaccharide (LPS) was similar in patients with acute disease when compared with that in normal control subjects. IL-1 was also spontaneously secreted in significantly greater amounts by patients with acute Farmer's lung than by subjects in a control group (p = 0.0001). However, LPS-induced IL-1 release was significantly diminished in BAL macrophages from patients with acute manifestations of the disease when compared with that in control subjects (p = 0.001). Treating hypersensitivity pneumonitis with corticosteroids or by contact avoidance resulted in very significant decrease in spontaneous and LPS-stimulated IL-1 production by BAL macrophages (p = 0.0001 and p = 0.03, respectively), as well as in a decrease in spontaneous TNF alpha release that was also significant (p = 0.01). In addition, BAL cells of patients in the acute phase had a significant NK cell activity (mean +/- SEM of 18.33 +/- 2.65%). Treatment of these patients resulted in an increase in NK cell activity (mean of 40.17 +/- 7.86%), which was significantly different from values of patients with acute disease (p = 0.037).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantification of histamine in plasma and pulmonary fluids from horses with chronic obstructive pulmonary disease, before and after 'natural (hay and straw) challenges'

A commercial radioimmunoassay kit was used to quantify histamine concentrations of plasma, bronchoalveolar lavage fluid (BALF) and pulmonary epithelial lining fluid (PELF) of normal horses and horses with chronic obstructive pulmonary disease (COPD), before and after 'natural (hay and straw) challenge' (NC). There were no significant changes in the concentrations of histamine in plasma or BALF at 0.5 or 5 h after NC, but the PELF histamine concentration of COPD affected horses was significantly increased at 5 h, but not at 0.5 h, following NC. As the histamine concentrations of whole BALF lysates were significantly correlated with the numbers of metachromatically staining cells, presumed to be mast cells and/or basophils, these findings support involvement of a late phase, IgE mediated, hypersensitivity reaction in the pathogenesis of equine COPD.

Endotoxin priming followed by high altitude causes pulmonary edema in rats

Rapid ascent to high altitude may be associated with the development of high-altitude pulmonary edema (HAPE) in susceptible individuals. Because lung lavage fluid obtained from such patients can be rich in protein and neutrophils, we considered that an element of lung injury and inflammation contributed to the pathogenesis of some forms of HAPE. On the basis of such a likely contribution of inflammatory mechanisms, we induced pulmonary lung injury and inflammation by priming rats with Salmonella enteritidis endotoxin (ETX) (0.1 or 0.5 mg/kg body wt ip) and examined the influence of added exposure to simulated hypobaric hypoxia (24 h, 4,300 m). The animals that were primed with ETX and exposed to hypoxia, but not those that received either ETX or hypoxia alone, developed lung vascular damage. This vascular damage manifested itself histologically and by increases in the lung vascular permeability-surface area product and the lung bloodless wet weight-to-dry weight ratio. The bronchoalveolar lavage fluid of ETX-primed hypoxia-exposed rats contained a greater number of white blood cells and a higher concentration of protein compared with that of the ETX-primed rats. Hearts of ETX + hypoxia-treated rats showed an increased ratio of right ventricular weight divided by body weight (RV/BW). Neutropenia prevented the development of pulmonary edema and the increase in ETX + hypoxia rats with a Ca2+ entry blocker inhibited lung injury and RV hypertrophy, these results indicate that ETX priming causes pulmonary edema at high altitude and suggest a role for neutrophils and Ca2+ in this rat model of lung injury.

Changes in bronchoalveolar lavage inflammatory cells in asthmatic patients treated with high dose inhaled beclomethasone dipropionate

Using serial bronchoalveolar lavage (BAL), we have studied changes in the airway inflammatory cell populations in 20 asthmatic patients, before and after treatment with inhaled beclomethasone dipropionate (BDP), 2,000 micrograms daily in an uncontrolled study. There was a significant improvement in asthma severity, as measured by symptom score and airways responsiveness, and there were significant reductions in the total BAL eosinophil, epithelial cell and mast cell counts, with a significant increase in the percentage BAL lymphocyte count. No significant correlations were found between the changes in airway inflammatory cell numbers and the reduction in asthma severity. In contrast, the fall in ROS generation by the pulmonary macrophage and granulocyte populations was nonsignificant, but the improvement in airways responsiveness was positively correlated to the reduction in the unstimulated pulmonary macrophage activity. Although these data are uncontrolled, the results are compatible with previous studies in suggesting an effect of steroids on the eosinophil, mast cell and epithelial cell in asthmatic airways. They also highlight the probable importance of the luminal lymphocyte population and pulmonary macrophage activation within the asthmatic airway, the beneficial modulatory effect of inhaled BDP treatment upon them, and the relative steroid-resistance of pulmonary inflammatory cell activity.

Role of beta 1, beta 2 integrins and ICAM-1 in lung injury after deposition of IgG and IgA immune complexes

After intrapulmonary deposition of IgG or IgA immune complexes, injury has been recently shown to be CD18-dependent in both cases and E-selection-dependent only in the former case. In our studies further evaluation of the requirements for beta 1 and beta 2 integrins and intercellular adhesion molecule-1 (ICAM-1) has been undertaken. In the IgG immune complex model, which is neutrophil dependent, anti-CD11a reduced injury (as measured by changes in permeability and hemorrhage) by 61 and 43%, respectively, whereas a newly developed anti-CD11b produced minimal protection (16 and 19%, respectively). Treatment of rats with increasing doses (1.5- and 3.0-fold) of antibody to rat CD11b failed to demonstrate additional protective effects in this model of injury. Anti-ICAM-1 reduced the parameters of injury by 61 and 78%, respectively, while anti-VLA-4 reduced the injury parameters by 40 and 35%, respectively. There were reductions in lung content of myeloperoxidase, roughly corresponding to the protective effects of the interventions. In the IgA immune complex model of injury, in which lung macrophages appear to be the effector cells, anti-CD11a reduced the injury parameters (permeability and hemorrhage) by 36 and 33%, respectively, whereas anti-CD11b reduced the parameters of injury by 63 and 67%, respectively. In this model, anti-ICAM-1 reduced the parameters of injury by 61 and 56%, respectively, while anti-VLA-4 reduced the parameters by 77 and 62%, respectively. The cell content of bronchoalveolar lavage fluids revealed changes that have been shown to reflect protective interventions in both models of immune complex-induced injury. These findings suggest that, in IgG and IgA immune complex models of lung injury, both VLA-4 and ICAM-1 are required, although lymphocyte function-associated Ag-1 is the predominant beta 2 integrin requirement in the IgG immune complex-induced model of injury and Mac-1 is the predominant requirement for IgA immune complex-induced lung injury. Thus, engagement in the lung of adhesion molecules in a manner leading to injury depends on the nature of the inflammatory stimulus and the type of phagocytic cells involved in the development of injury.